out of the frying pan & into the fire
DESCRIPTION
Out of the frying pan & into the fire. Dr Duncan Anderson Vascular Surgeon www.drduncananderson.co.za. The frying pan. Traditionally the surgeon has been based in the operating theatre Preoperative angiography was routinely performed by the radiologist. Case 1: Critical limb ischaemia. - PowerPoint PPT PresentationTRANSCRIPT
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Out of the frying pan& into the fire
Dr Duncan AndersonVascular Surgeon
www.drduncananderson.co.za
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The frying pan
• Traditionally the surgeon has been based in the operating theatre
• Preoperative angiography was routinely performed by the radiologist
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Case 1: Critical limb ischaemia
• 61 year old male• Non-healing left ankle
ulcer for 9 months• Risk factors: heavy
smoker, hypertension & hypercholestrolaemia
• Only left femoral pulse• Ankle brachial index:
0.46
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Case 1: Critical limb ischaemia
• Catheter directed angiogram in the cathlab
• Left femorodistal bypass to the posterior tibial artery
• Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein
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Case 1: Critical limb ischaemia
• Who should be referred to a vascular surgeon?
• And which special investigations should be performed prior to referral?
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Who should be referred?
• Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene
• All patients with ankle brachial index <0.9• Any diabetic, chronic renal failure patient or
heavy smoker with absent pedal pulses
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Which special investigation?
• Ankle brachial index (ABI) only– ABI 1.3-0.9 manage vascular risk factors– ABI 1.3-0.9 safely apply compression bandaging
for venous stasis ulceration• No arterial duplex doppler ultrasound• No CT angiography• No MR angiography• No cathlab angiography
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The fire
• Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography
• Cathlab• Hybrid theatre• Offers a more goal
directed therapy
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Case 2: Complex varicose veins
• 36 year old female• Recurrent bilateral
varicose veins• Vein surgery in 2005• Pelvic congestion
syndrome– Menorrhagia– Dyspareunia– Dysmenorrhoea
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Case 2:
• Suspect pelvic /ovarian vein reflux– Recurrent varicose veins– Atypical varicose veins– Extensive groin
varicosities– Vulvae varicosities– Pelvic congestion
syndrome
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Case 2: Complex varicose veins
• CT venography• Not a routine special
investigation (timing critical)
• Catheter directed venography
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Case 2: Complex varicose veins
• Traditionally vein ligation & stripping
• Endovenous laser or radiofrequency (VNUS) ablation– No groin wound– No thigh bruising– Less postoperative pain– Earlier mobilization
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VNUS ablation
• Radiofrequency ablation
• Cathlab or rooms• Ultrasound-guided• Tumescence infiltration• Immediate ambulation
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VNUS ablation
• Tumescence infiltration– Local anaesthesia– Facilitates ablation by
vein compression– Reduces risk of deep
vein thrombosis– Creates “heat sink” to
protect surrounding tissue
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VNUS ablation
• Less pain & less bruising than laser ablation
• Who should be referred to a vascular surgeon?
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Who should be referred?
• Atypical distribution of varicose veins• Recurrent varicose vein• Associated chronic venous insufficiency
(venous stasis dermatitis or venous ulcer)• Suspicion of pelvic/ovarian vein reflux• VNUS ablation for better cosmetic result, less
pain & immediate mobilization
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Case 3: False aneurysm
• 49 year old female• Painful swelling right
groin 2 weeks after cathlab
• BMI 40.4• Large false aneurysm
flush with common femoral artery (no neck)
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Case 3: False aneurysm
• Direct surgical approach• Burst on skin incision• Direct digital control of
2cm defect in common femoral artery
• Total of 4 unit blood transfusion
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Case 3: False aneurysm
• Proximal control digitally through pelvis
• Repaired with vein patch
• Discharged after 6 days• High risk of wound &
graft sepsis
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Case 3: False aneurysm
• Negative surgical aspects– Additional open surgical
procedure– Risk of anaesthesia– Prolonged hospital stay– Postoperative pain– High risk of wound &
graft sepsis– Difficult mobilization
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Case 4: False aneurysm
• 74 year old female• Painful right groin
swelling 1 day after cathlab
• BMI 32.2• Dropped haemoglobin
from 13g% to 9g%
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Case 4: False aneurysm
• Long & narrow neck• Ultrasound-guided
thrombin injection
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Case 4: False aneurysm
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Case 4: False aneurysm
• Angioplasty balloon to arrest flow within aneurysm
• Thrombin (factor IIa) converts fibrinogen to fibrin
• Discharged within 48hrs
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“If all that you have is a hammer,then all that you’ll see are nails”
UROLOGIST VASCULAR SURGEON ANAESTHETIST